Get Fp17r 11 Pdf

Completing the Fp17r 11 Pdf online can streamline your process for claiming a refund for a replacement NHS dental appliance. This guide provides clear and organized steps to help you fill out the form accurately and efficiently.

Follow the steps to complete the Fp17r 11 Pdf online

1. Click the ‘Get Form’ button to access the Fp17r 11 Pdf. This will allow you to download and open the form for editing.
2. Begin by filling in the patient’s details in Part A. Use block capitals to write the surname, forename, date of birth, sex, contact number, and address. Ensure you also complete the postcode.
3. If the patient is under 16, provide the surname of the parent or guardian in the designated field.
4. In Part B, indicate the title and initial of the account holder(s) for the refund. Fill in the full name of the bank or building society and the sort code, ensuring accuracy to avoid delays.
5. Complete the account number and, if applicable, the building society roll or reference number. If there is no account, tick the appropriate box.
6. In Part C, the dentist needs to provide their name, address, and location number.
7. Proceed to Part D, recording the date the appliance was provided and the date the charge was paid. Include the amount charged, indicated in pounds.
8. Attach a receipt for the charge to support your claim.
9. In Part E, describe how you cared for the appliance before it was lost or damaged, detailing the circumstances of the damage.
10. In Part F, confirm that the appliance was not lost or damaged due to a lack of reasonable care.
11. Indicate in Part G if this charge will cause undue financial hardship and provide supporting evidence such as benefits information or exemption certificates.
12. In the patient’s declaration section, certify that the provided information is accurate, sign, print your name, and include the date.
13. Finally, once the form is complete, save your changes, and you can choose to download, print, or share the form.

Start completing your Fp17r 11 Pdf online today!